Repeated warnings
Each one is a single concern, raised with the same organisation in two or more coroners' reports at least six months apart. Nemotron Super judged every match to be the same or a closely related hazard, and both quotes are checked word for word against the reports.
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Organisation type
Theme
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At least
29 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Shortage of tier 4 paediatric mental health beds
NHS England · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - Fragmented communication between mental and physical health services
Southern Health NHS Foundation Trust · NHS body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - 2 reports · 2 coronersIdentical hazardConfidence 0.92 · highNo published response to an earlier report
- 2 reports · 2 coronersIdentical hazardConfidence 0.92 · highNo published response to an earlier report
- Unrestricted domestic purchase of substance
Home Office · National body
2 reports · 1 coronerIdentical hazardConfidence 0.96 · high - Delayed staff training on cell entry and emergency communications
Ministry of Justice · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - 3 reports · 3 coronersIdentical hazardConfidence 0.90 · high
- 2 reports · 2 coronersIdentical hazardConfidence 0.92 · highNo published response to an earlier report
- Recurring hazard (see the quoted concerns)
His Majesty's Prison and Probation Service · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - Detention without section due to bed shortage
NHS England · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - 2 reports · 2 coronersIdentical hazardConfidence 0.95 · high
- Unrestricted online purchase of lethal prescription medication
Department of Health and Social Care · National body
5 reports · 5 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - 3 reports · 3 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report
- Inconsistent sharing of medical notes between agencies
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - Delayed discharge of out-of-area patient
NHS England · National body
2 reports · 1 coronerIdentical hazardConfidence 0.95 · high - Delayed mental health bed allocation leading to patient deterioration
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - 2 reports · 1 coronerIdentical hazardConfidence 0.90 · high
- 2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report
- Lack of automated medication compliance alerts
NHS England · National body
2 reports · 2 coronersIdentical hazardConfidence 0.92 · highNo published response to an earlier report - Incompatible electronic records between mental and physical health services
Department of Health and Social Care · National body
2 reports · 1 coronerIdentical hazardConfidence 0.90 · high